A Simple Guide to Pneumothorax

A Simple Guide to Pneumothorax
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What is Pneumothorax?
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Pneumothorax is a medical emergency caused by collection of air in the pleural space between the perietal and visceral pleura.

What are the types of pneumothorax?
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Tension pneumothorax:
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This ia a medical emergency as air builds up in the pleural space with each breath.
The rising intrathoracic pressure pushes the mediastinum away from the affected lung to the other compressing intrathoracic vessels and causing collapse of the lung.
Tension pneumothorax are life threatening.

Non-tension pneumothorax:
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A non-tension pneumothorax is less serious because there is no increasing pressure of air in the thoracic region and hence no increasing pressure on the intrathoracic organs.

Hemopneumothorax:
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When blood accumulates in the thoracic cavity (hemothorax), there is even more increased pressure in the pleural cavity. This is called a hemopneumothorax and also be life threatening.

What is the causes of pneumothorax?
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It is most commonly due to:

Spontaneous pneumothorax
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This is due to the rupture of superficial air sacs following severe coughing or strenous exercise in:

1.tall young males and in Marfan syndrome

2.Tuberculosis

3.Bronchial obstruction

4.Cancer

Non-spontaneous pneumothorax
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1.penetrating chest wound

2.surgical trauma

3.pleural effusion tap

What are the Signs and symptoms of Pneumothorax?
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Symptoms:
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1.Sudden onset of chest pain, back

2.shortness of breath,

3.dry coughs,

4.cyanosis (turning blue)

5.coma

Signs:
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1.Pale or cyanotic

2.Percussion show resonance at normal lung while none at the pneumothorax lung area

3.Auscultation reveals breath sounds on the normal side but none at the pneumothoracic lung

4.There may be a characteristic clicking sound with respiration.

5.In penetrating chest wounds, there is a typical "sucking" sound of air flowing through the puncture hole .

6.The flopping sound of the punctured lung can sometimes be heard

How is the Diagnosis of Pneumothorax made?
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Physical examination:
a. absence of audible breath sounds through a stethoscope

b. hyperresonance (higher pitched sounds than normal) to percussion of the chest wall is suggestive of the diagnosis.

c.Two coins when tapped on the affected side results in a tinkling resonant sound

Chest X-ray reveals a typical pattern of complete lung collapse with air space surrounding the lung edge.

Medistinal shifts can be seen on inspiratory and expiratory films

CT scan and MRI can revealed a clearer picture of the pneumothorax and even the bubbles on the lung surface which may burst and cause a pneumothorax.

What is the complication of Pneumothorax?
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Respiratory failure with circulatory collapse

What is the treatment of Pneumothorax?
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All pneumothorax patients are to be admitted to hospital for treatment.

1. Small spontaneous pneumothorax
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A small spontaneous pneumothorax can be left alone to reabsorb on its own.

The patient is monitored in hospital and given oxygen until the pneumothorax has disappeared.

2.Tension Pneumothorax
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Tension Pneumothorax is a medical emergency.

Any perimedic or doctor attending to the patient should insert a needle immediately into the pleural cavity to allow the air to escape.

Tube drainage can also be done if available. If the tube is not available, immediate evacuation to the hospital should be done for advanced medical care.

The tube should be inserted with underwater seal and suction of the air out of the pleural cavity done using a simple one way valve or vacuum and a water valve device, depending on severity.

The lung should re-expand in the thoracic cavity nad the result is monitored by frequent x-rays

Where rarely the chest tube does not help healing of the lung , surgery may be done to staple the lung closed.


Penetrating wounds:
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A chest drain is inserted first before any treatment of the wounds is done.

Supprtive treatment:
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Oxygen therapy
Rest
Antibiotics for infections
Painkillers for pain


Recurrent pneumothorax
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1.pleurodesis may be required in recurrent pneumothorax.

2.bullectomy (the removal or stapling of bullae).

3.Chemical pleurodesis uses chemical irritant that leads to adhesion of the lung to the parietal pleura.

4.Mechanical pleurodesis The inside chest wall is roughened so the lung attaches to the peural wall with scar tissues

5.pleurectomy is the removal of the parietal pleura which can be performed using keyhole surgery

What is the prognosis of Pneumothorax?
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It is usually good following treatment.

However treatment is always needed to address the cause of the underlying diseases causing the pneumothorax.

A Simple Guide to Headache

A Simple Guide to Headache

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What is Headache?

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Headache is a very common complaint, not an illness.

It literally means pain in the head.

What are the Common Types of Headaches?

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Tension headache:

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as defined by the International Headache Society is characterised by:

1.bilateral location

2.pressing/tightening (non-pulsating) quality

3. mild to moderate in intensity

4. not aggravated by routine physical activity like walking or climbing stairs.

It is the most common headache and may be associated with contractions of head and neck muscles due to physical or mental stress. The headache is made worse by changes in the environment, drugs, or factors unique to the individual.

It can also be classified into 2 side types:

episodic (<>

chronic (> 14 days a month on average and <>

Treatment can be divided into:

pharmaceutical

non pharmaceutical

Pharmaceutial:

can be divided into acute and prophylactic.

In acute treament simple painkillers is usually effective.

In prophylactive treatment,antidepressants like amitriptyline usually help in the prevention of tension headache.

Medicines should always be given at low doses and titrated up to therapeutic doses to minimise side effects.

Non-pharmaceutical:
1. rest

2. removal of aggravating factors.

3. relaxation exercises

Migraine:

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is defined as a heavy throbbing pain usually over one side of the scalp, forehead and about the eye, caused by abnormally dilated blood vessels.

Migraine may be accompanied by nausea, vomiting or sensitivity to loud noises or bright lights.

It is also triggered by certain factors unique to the individual such as:

1.menstruation,

2.alcohol,

3.anxiety,

4.loud noises,

5.bright lights

A validated 3 items questionaire covering

1. disability

2. nausea

3. sensitivity to lights

should given to every patient to screen the severity of the migraine.

Treatment again is divided into:

phamaceutical

non-pharmaceutical.

Pharmacetical:

can be divided into acute and prophylactic.

In acute treament simple painkillers like paracetamol is usually effective in mild cases.

Non-steroidal anti-inflamatory drugs should be tried if paracetamol fails.

If NSAIDs are ineffective then migraine-specific drugs like triptans or ergotamine which act to constrict blood vessel should be tried.

In some cases anti-emetic drugs like stemetil to prevent vomiting is given together with the migraine medication.

In prophylactic treatment, the goals are to:

1. reduce frequency,severity and duration

2.improve function and reduce disability

3.improve responsiveness to treatment of acute attacks

Medicines used include:

betablockers

Calcium channel blockers

Serotonin receptor antagonists

Antidressants

Anticonvulsants

Angiotensin blockers

NSAIDs

Non-pharmaceuticals:

1.resting in a cool, dark and quiet room.

2.relaxation exercises

3.Solving the triggering factors also help.

4.Oestogen containing oral cotraceptives should avoided in menstrual migraine.

During pregnancy or lactation treatment should be non-pharmaceutical when possible. If necessary paracetamol is the safest drug for women during pregnancy or lactation.

Cluster headaches

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is defined as pain which occurs in runs with tearing pain over the forehead or behind the eye(s) with flushing of the face.

There are aura of stars,flashing lights etc associated with this headache.

The cause is beleived to be due to histamine release from ingestion of certain foods like cheese, seafood,alcohol etc.

It is more common in males.

Treatment is by

1.strong painkillers

2.avoidance of food triggers

3.rest.

What are Secondary headaches?

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Secondary headaches refer to headaches associated with a known medical illness.

It is diagnosed by its close relation to a disorder that is known to cause headache.

The headache improves or disappear after successful treatment or spontaneous resolution of the causative illness.
1.Sinus headaches:

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are due to acute sinus inflammation attacks.

Pain is over the frontal forehead and the upper cheeks.

It may be associated with fever and heavy mucus production.

Treatment is by

1.antibiotics for the sinus infection,

2.antihistamines to reduce mucus production

3.painkillers

4.rest.

2.Referred headaches:

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these are caused by by referred pain from disorders of structures around the head. Common ones are

1. earaches,

2. toothache causing pain over an entire part of the face and

3. temporomandibular joint dysfunction from mechanical pain from the jaw joint.

4. temporal arteritis, a rare inflammatory blood vessel condition causing persistent headache at the temporal artery. There is possible complication of blindness secondary to anterior ischemic optic neuropathy. The headache usually resolves or improves with 3 days of high dose steroid treatment.

3.Meningitis / Encephalitis headaches:

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caused by infection of the brain tissue (encephalitis) or the membranes surrounding the brain (meningitis).

Headache is the most common symptom. The pain is diffuse and progressive with fever, a painful stiff neck and other symptoms such as drowsiness, seizures and neurological problems including weakness and numbness.

This type of headache needs immediate hospital treatment.

4.Cerebrovascular Accidents (haemorrhagic stroke):

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a stroke happens when a blood vessel in the brain is blocked or bursts.

Bleeding in the brain causes a sudden severe headache.

There is also associated loss of consciousness and other neurological signs such as weakness, numbness and seizures.

This type of headache needs immediate hospital treatment.

5.Brain Tumour:

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is rare and causes a gradual headache lasting for weeks.

It is localised and associated with nausea, vomiting, loss of appetite and loss of weight.

It is worse in the morning and aggravated by coughing or leaning forward.

By the time neurological symptoms appear such as seizures, numbness, weakness or blindness, the brain tumour has already grown to an advanced stage.

Treatment includes surgery, chemotherapy or radiotherapy.

6. Other causes of secondary headaches are:

a.post traumatic headache following a head injury

b.whiplash injury

c.cerebral venous thrombosis

d. idiopathic intracranial hypertension

e. hydrocephalus

f. sleep apnea

g.cardiac cephalgia

h.acute glaucoma

Simple Treatment of Headache

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Consume a painkiller.

Lie down in a dark, quiet room.

Use muscle relaxation techniques or a gentle massage.

For tension headaches, try a warm bath.

For migraines, put an ice bag or cold towel on your temple.

If the headache do not improve, go for a complete investigation of the headache.

What are the investigations done in Headache?

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You should be investigated for your headache if the headache has:

1. associated fever and and change in mental state.

2. numbness of part of the body or with paralysis.

3. associated fits.

4. sudden onset of severe headache

5. lasted for more than a day even after taking painkillers.

6. increased headache frequency.

7. appeared different from your usual type

8. been precipitated by coughing,sneezing,bending

9. associated with stiff neck and vomiting

10.appeared for the first time in middle age

Common tests:

Blood tests - for infections,raised ESR, bleeding disease

MRI of brain- to exclude brain tumours, bleeding in the brain

Lumbar puncture - used only if there is suspected infection of brain or meninges