INSTRUCTION

Examine this patient's chest.

SALIENT FEATURES

History

· Sudden onset or rapidly progressive dyspnoea.

· Ipsilateral acute pleuritic pain - the pain is either sharp or a steady ache.

· A small pneumothorax may be asymptomatic.

· Obtain history of recent pleural aspiration or insertion of subclavian line (J R Soc Med 1997: 90: 319-21), recent surgery to

head and neck, abdominal procedures using bowel or peritoneal distension.

· History of asthma, COAD, ARDS, pneumonia, trauma to chest.

· History of Marfan's syndrome.

· History of HIV.

· History of positive pressure ventilation.

Examination

· Decreased movement of the affected side.

· Increased percussion note.

· Trachea may be central (small pneumothorax) or deviated to the affected side (underlying collapse of lung) or the opposite side

(large pneumothorax).

· Increased vocal resonance with diminished breath sounds.

Proceed as follows:

· Look for clues regarding aetiology:

-Pleural aspiration site.

-Infraclavicular region for a bruise from the central line.

-Comment if the patient is thin or has marfanoid features.

Inhaler or peak flow meter by the bedside (asthma, COAD).

· Tell the examiner that you would suspect tension pneumothorax when there is tachycardia (>135 beats/minute), hypotension

and pulsus paradoxus.

DIAGNOSIS

This patient has diminished breath sounds and hyper-resonant note on R/L side of the chest (lesion) due to pneumothorax

secondary to Marfan's syndrome (aetiology), and is not breathless at rest (functional status).

Read recent review: N Engl J Med 2000; 342: 868-74.

QUESTIONS

What do you understand by the term 'pneumothorax'?

Air in the pleural cavity.

How would you investigate this patient?

· CXR, both inspiratory and expiratory phases. In critically ill patients pneumo-thorax is suspected when (a) the costophrenic

angle extends more inferiorly than usual due to air- the 'deep sulcus sign' (Radiology 1980; 136: 25-7), (b) liver appears more

radiolucent due to air in the CP angle, or on the left side, when the air will outline the medial aspect of the hemidiaphragm

under the heart.

· Blood gases if the patient is breathless: hypoxaemia depending on the shunting,

whereas hypercapnia does not develop.

ADVANCED-LEVEL QUESTIONS

How would you grade the degree of collapse?

British Thoracic Society grading:

· Small: where there is a small rim of air around the lung.

· Moderate: when the lung is collapsed towards the heart border.

· Complete: airless lung, separate from the diaphragm (aspiration is necessary).

· Tension: any pneumothorax with cardiorespiratory distress (rare and requires immediate

drainage).

How would you manage this patient?

· Small pneumothoraces (less than 20% in size) spontaneously resolve within

weeks.

· Larger ones (irrespective of size) with normal lungs are managed by simple aspir-ation rather than an intercostal tube as the

initial drainage procedure. Aspiration is less painful than intercostal drainage, leads to a shorter admission and reduces the

need for pleurectomy with no increase in recurrence rate at 1 year.

· When there is rapid re-expansion following simple aspiration, an intercostal tube with underwater seal drainage is used. The

tube should be left in for at least 24 hours. When the lung re-expands, clamp the tube for 24 hours. If repeat radio-graphy

shows that the lung remains expanded, the tube can be removed. If not, suction should be applied to the tube. If it fails to

resolve within I week, surgical pleurodesis should be considered. Video-assisted thoracoscopic surgery with several chest ports

allows clear visualization of the pleural cavity for resection of bullae and pleurodesis.

What are the causes of pneumothorax?

· Spontaneous (usually in thin males).

· Trauma.

· Bronchial asthma.

· COAD - emphysematous bulla (JAMA 1975; 234: 389-93).

· Carcinoma of the lung.

· Cystic fibrosis.

· TB (the original descriptions of pneumothorax were commonly associated with

TB, JAMA 1931; 96: 653-7).

· Mechanical ventilation.

· Marfan's syndrome, Ehlers-Danlos syndrome.

· Catamenial pneumothorax, i.e. pneumothorax that occurs in association with menstruation.

How would you perform a pleurodesis?

By injecting talc into the pleural cavity via the intercostal tube.

In which patients would you avoid doing a pleurodesis?

In patients with underlying cystic fibrosis. These patients may require lung trans-plantation in the future and pleurodesis may make

this procedure technically not feasible.

When would you suspect a tension pneumothorax?

Tension pneumothorax should be suspected in the presence of any of the following:

· Severe progressive dyspnoea.

· Severe tachycardia.

· Hypotension.

· Marked mediastinal shift.

When should open thoracotomy be considered?

It should be considered if one of the following is present:

· A third episode of spontaneous pneumothorax.

· Any occurrence of bilateral pneumothorax.

· Failure of the lung to expand after tube thoracostomy for the first episode.

O.K. Williamson (1866-1941), an English physician, described the Williamson sign, i.e. blood pressure in the leg is lower than that in

the upper limb on the affected side in pneumothorax.

INSTRUCTION

Examine this patient's chest.

SALIENT FEATURES

History

· Fever and night sweats.

· Malaise, fatigue, anorexia.

· Weight loss.

· Cough with sputum.

Examination

These'patients tend to have signs of common chest diseases which are not cut and dried. There are several masons for this, such

as pleural thickening, thoracotomy and pneumonectomy, associated COAD, associated chest infection, plombage or phrenic nerve

crush.

The following provide some examples:

Patient 1

The candidate was asked to examine the chest from the front, as a result of which the old thoracotomy scar was not seen. The

patient was wheezy. The trachea was deviated to the right. Percussion note was stony dull from the right second inter-costal space

downwards. Wheeze was present on the left side. This patient had a right pneumonectomy with COAD in the left lung. The

candidate's diagnosis of right-sided pleural effusion with underlying collapse and left-sided COAD was accepted.

Patient 2

The trachea was central. A phrenic nerve crush scar was seen. Percussion note was dull in the left infra-axillary region and there

were associated crackles. The diag-nosis of pleural thickening with associated chest infection was accepted; that of pleural effusion

was not.

QUESTIONS

How would you manage a patient with old tuberculosis?

Old tuberculosis requires no antituberculosis treatment. However, the patient may require symptomatic treatment for wheeze and

shortness of breath.

In which groups of people is the risk of tuberculosis high?

· Asian and Irish immigrants.

· The elderly.

· Immunocompromised individuals, particularly AIDS patients.

· Alcoholics.

* Occupations at risk: doctors, nurses, chest physiotherapists.

ADVANCED-LEVEL QUESTIONS

Would you isolate a patient with newly diagnosed, sputum-positive, pulmonary TB?

Yes. Segregation in a single room for 2 weeks is recommended for patients with smear-positive tuberculosis. Barrier nursing,

however, is unnecessary. Adults with smear-negative or non-pulmonary disease may be in a general ward. A child with TB should

be segregated until the source case is identified as this person may be visiting the child.

How are contacts investigated?

Contacts are investigated by inquiry into bacille Calmette-Gudrin (BCG) vac-cination site, Heaf testing and CXR examination.

To whom would you offer BCG vaccination?

BCG vaccination is offered to previously unvaccinated, persistently Heat' test-negative or grade 1 contacts aged under 35 years

unless there is a special occu-pational, travel or ethnic risk. Patients with known or suspected HIV infection should not be offered the

vaccination.

What are the indications for chemoprophylaxis?

· Chemoprophylaxis may be given to those with strongly positive Heat' test reactions but no clinical or radiological evidence of

TB (Thorax 1994; 49:1193-200).

· Chemoprophylaxis should be given to children under 5 years who are close contacts of a smear-positive adult irrespective of

their tuberculin test result.

· If chemoprophylaxis is not undertaken, follow-up with periodic CXR examin-ations for 2 years is recommended in all these

groups.

Which rapid test allows early diagnosis of tuberculosis?

Polymerase chain reaction (PCR).

Robert Koch (1843-1910), Institute for Infectious Diseases, Berlin, was awarded the 1905 Nobel Prize for Medicine for his

investigations and discoveries in relation to tuberculosis.

Kary Mullis of the USA was awarded the Nobel Prize for developing the technique of polymerase chain reaction.

Examine this patient's chest.

SALIENT FEATURES

History

· History of TB, ankylosing spondylitis, radiation.

· History of phrenic nerve crush, plombage, thoracotomy.

Examination

· The fibrosis is usually apical.

· Flattening of the chest on the affected side.

· Tracheal deviation to the affected side.

· Reduced expansion on the affected side.

· Dull percussion note.

· Presence of localized crackles; bronchial breathing may be present.

Proceed as follows:

Look for the following signs:

· Scars of phrenic nerve crush, plombage, thoracotomy.

· Radiation scars.

DIAGNOSIS

This patient has flattening of the R/L side of the chest with diminished movements on that side, tracheal deviation and localized

crackles (lesion) due to pulmonary fibrosis secondary to tuberculosis (aetiology), and is comfortable at rest (functional status).

QUESTIONS

Mention a few causes of upper lobe fibrosis.

* Tuberculosis.

· Ankylosing spondylitis.

· Radiation-induced fibrosis.

ADVANCED-LEVEL QUESTIONS

Which is the best imaging procedure for the upper lobe lesions?

MRI is better for upper lobe lesions than CT of the chest.

What is the role of MRI of the thorax?

MRI of the thorax is less useful than CT scanning because of poorer imaging of the pulmonary parenchyma and inferior spatial

resolution. However, MRI can provide images in multiple planes (e.g. sagittal, coronal as well as transverse) which CT can not. MRI

is excellent for evaluating processes near the lung apex, spine and thoraco-abdominal junction.

On 8 November 1895 R6ntgen discovered what he called X-rays. In the subsequent

7 weeks he meticulously performed experiments, and an X-ray picture of his wife's hand convinced him about the potential role of the new ray. In 1901 he was awarded the

Nobel Prize for physics.

Hounsfield's work on CT in the EMI laboratories at Hounslow made it possible to obtain detailed cross-sectional views of the soft tissues, particularly the brain.

Sir Godfrey N. Hounsfield (1919-) and Alan M. Cormack (1924-), the latter of Tufts University, Boston, were jointly awarded the 1979 Nobel Prize for Medicine for the

development of computer-assisted tomography.