Sun28November0440PM 42

A 23-year-old woman with no history of trauma is admitted to the Emergency department with pleuritic chest pain and exertional dyspnoea.

A standard erect PA chest radiograph shows a 4 cm apical pneumothorax. The chest physician decides that a chest drain should be inserted as soon as possible.

Which one of the following options is the most appropriate technique?

(Please select 1 option)

Insertion of a large bore chest drain using blunt dissection in the mid-axillary line

Insertion of a small bore chest drain using a Seldinger technique in the mid-axillary line Correct

Insertion of a large bore (posterior) suprascapular apical chest drain using blunt dissection

Insertion of a small bore chest drain using a Seldinger technique in the posterior axillary line

Insertion of a small bore chest drain using a Seldinger technique in the second intercostal space mid-clavicular line

Explanation

Small bore drains are just as effective as large bore drains and are less painful when in situ.

The most appropriate point for chest drain insertion is in the 'safe triangle' in the mid-axillary line. This reduces the chance of injury to the internal mammary artery, muscle, liver and spleen. Scarring from insertion is less obvious than in the second intercostal space and mid-clavicular line, particularly important in women.

The choice of initial intervention for a pneumothorax of this nature should take into account operator experience and patient choice; needle aspiration (NA) is less painful than chest drain insertion may fail in approximately one-third of patients and will require a second procedure. Other national and consensus guidelines recommend either NA or small-bore chest drain insertion,97 or chest drain insertion alone. The British Thoracic Society believe that NA remains the procedure of first choice in most cases.

Loculated apical pneumothoraces may be drained using a posteriorly sited (suprascapular) apical tube but are not recommended in this scenario. If the pneumothorax is loculated as demonstrated by a CT scan a more posterior insertion site might be selected. This is not the case with this patient.

Reference:

MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. Volume 65 Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010 | Thorax

Answer Statistics

1

5%

2

81%

3

1%

4

2%

5

12%

Times answered: 300