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in a room here. Me? Okay. Okay, so this is just a correct wrong three off pneumothorax. And so we covered all the definition signs and symptoms investigation management, and then a couple of case examples. So pneumothorax on it's very basic level is Aaron pleural space, and they're mostly divided under primary spontaneous pneumothorax. So that's a pneumothorax occurring and otherwise healthy, Long on a second. And, um, thorax, which pneumothorax associated with an underlying disease. And traditionally that was TB. Nine days of COPD tremor mostly, and primarily mostly, effects younger people. So take it. Script is 20 to 36 to one meal reissue. I'm usually a ruptured subdural Blair. Typically, it's you're tall, thin, athletic thing. Humira may not smoke on. 25% of those will record within a year. Second month or she's tend to be the 60 to 70 year old. Again. There's a meal performance on a little something 321 and various underlying causes of disease process and on up to 50% will occur within a year without treatment. But it varies by the underlying cause, so that could be classified by size or smaller. Pneumothorax is less than one centimeter moderate is 1 to 2 on the large is greater than two centimeters. Those measurements are taken at the level of the hilum on some regions, especially America, and the depth the pneumothorax is measured at the apex. But and here on everything I'm talking about, this measures level the hilum attention hemothorax, and it's wellness. Under pressure is that causes decreased venous return to the heart on contraceptive cardiac arrest. So usually they're sudden onset. Best on predict PM and there, maybe hypoxia or cyanosis. There's usually decreased air entry and decrease chest wall movement. On the affected side, there's a hyper isn't precaution note, and they can be toxic arctic on the kind of pulses part oxidase eso. With that, the heart rate slows down on inspiration. If you find someone trivial, deviation the standard vaccines feeling of impending doom and circulatory clubs, that's more a sign of a tension your mouth or extend that needs dealt with emergency. So, as I said, if you're worried about tension doing brother investigating, just go straight. Definitive management. Chest X ray is about 85% sensitive for pneumothorax. Obviously, there's occasionally artifacts of skin. Fools border the scapula on cardiac leads, oxygen, Children and so on person is up to 95% sensitive. All of that comes with an asterisks at the pants off was doing it on my scale, the heart ultrasound and you can do blood and 80 to expect other diagnoses. And And if it's any queer, your concern and particularly and secondly, um, authorities. Where there may be a bill and other lung problems, it's not on there. It's not, uh, and appropriate to get a CT. So in terms of management, this is just lifted straight from the BTS guidelines. Eso they have my salad rhythm. All the spontaneous pneumothorax are they used over 50 with the smoking history or evidence of any underlying disease. That's a second with the rocks. And if it's grinning two centimeters or the patient is subjectively breathless, they proceed. Strip to dream. If it's 1 to 2 centimeters of a moderate size, you can ask for it, and on depending on whether that successful in upstate getting tree, and they get admitted for a tradition and for the younger, healthy population with primary of thorax, if it's greater than two centimeters or their breathless and first step is operation. It's not successful than it's observation and with an outpatient followup, whatever. If they're not better after your operation than you proceed, you dream So. As I said, you can monitor when you come out of these conservatively. And so usually the patients put on high flu oxygen therapy, assuming that they're not a normal teenager, not increases the real of resolution by a factor for if you manage them completely conservatively and ambulatory. So what? They've been in hospital as the pneumothorax will resolve how to really wait 2% off a heavy thorax per day. So if you have a one centimeter pneumothorax, the level of the hilum that is roughly 25% of the volume off the hemithorax that resolves in 12 or 13 days and he come on, it's these quite safe and successfully is a non military case. But if there's any concern, speak with somebody seeing you on the floor. The only caveat is that all secondary majorities should be admitted for observation and because they are far more likely to need a dream. And I know there was just a talk on chest Reines. Unfortunately, I wasn't here for us. I don't know what exactly was covered. So policies of this is just like a shin on for needle aspiration. Essentially marker spot on the skin, which is in the midclavicular nine. The second intercostal space. Uh, clean it. And if it dies of a nuisance aseptic technique user a navy cannula. Have the 10 minutes range in some saline in it, so that when you're in the Urals fiercely ask you get bubbles of Harrison, you're in the right place and then taking the light touch three. A connector on extension set to the needle, and then you can ask it up to 2.5 liters. It's not 50 military inj with 50 pills, and so it's kind of time consuming exercise, and you can ask me about the 10 a half liters, or to the point where the patient starts coughing and used that in the kids. When the Pridol on Vistaril Vera are coming back into contact with each other, so have aspirated the pneumothorax that point you can take any light, put on a dressing on, repeat the X ray to see if you've been successful, and if you have been, then that good on the ambulatory route. If not, then they would need to proceed to chest re. Um, so for the most part, that's a seldinger cream, and it's placed in the triangle, See if things. So you see this patient? That's a triangle from pack major, the Testim, its doors say, on the level off the fifth intercostal spaces, which is usually the nipple that and, um on that. Hasn't you know, I'm not going to too much detail that hope it's covered in the chest, re in talk. And if not, it's not something you can there enough apartment slide. It's something that you need to go through on. There are courses available in, as in Belfast in this imitation sweet for chest reinsertion. In terms of ongoing management, If they have a dream in situ on or their second pneumothorax, they get admitted, and I think we're on a conservative management roots. You can consider admission for auction therapy in order to speed up the resolution if they're fit for home, And the guidelines say they need a respiratory physician review within two weeks. And again, it comes to the caveat that everyone knows that you're not going to get an appointment in two weeks. So having a senior 80 review is acceptable and that sort of circumstance and I should get written discharge device. So there's a advice on simply need to be printed and given to them with Safety net. And so if they get more breathless if they get more PM, If there's any concerns, they should return to eat a. And if they are a smoker, that should be given smoking cessation advice. Although even and smokers with near new authorities, the cessation is only 20% and they should avoid flying for one week after the have a full resolution on a chest X ray on the advice is that they should never dive. So know scoop equipment dependent on occupational history. If they are a pilot, far fighter or other occupations, it should be pointed towards your own occupational health department because it can have quite a wide range of implications for them. Sometimes you need more follow up, so if they have a second episode of pneumothorax of tune your mouth or is it on the same side? If they have controller, come tonight on the majority's so one of the side separated by time. If they have bilateral spontaneous pneumothorax or two months if they have a persistent there a week or the lung fields re expand after having a chest. Reason for five days. If there's an associate hemothorax, if they're at rest, professions of pilots, divers and so on, or, if they're pregnant, not covered the sort of medical in your mouth or oxide in terms of traumatic pneumothorax. We're getting better diagnosing these because a lot of patients proceed. Strip the pants can see he's so little difficult you maturity that were never picked up on X ray or nine, and she leads to. Then tree is being put in where they may not necessarily be needed. Today chi quite a lot of fertility and morbidity, so if you have a patient with a pneumothorax, I would probably put entry. And if there's a concurrent chemo thorax, it's large enough to be seen on the chest X ray or the skate. Do you of the CT? It was a moderate are large pneumothorax, so something with enough space to put a drain into, and not just a little atypical pneumothorax. If the patient is for intubation of ventilation. So if we're going to, I see you or if you're going to theater and there's a theory that the positive pressure ventilation can worsen there and you move, so consider a drink that point. And if you had to do a needle Thorkelson your finger. Third cost me, and I'm usually in cases. Penetrate and traumas were gunshots and stab ones terms off kiss examples. And it's a 22 year old meal smoker with a sudden last site of product, Caspian, who was short of breath on exertion, so I don't know how well it comes across. And but there's a little typical pneumothorax. And then, when you follow down level, the hilum heads touching the chest wall kind of kiss. You could consider a man in fraction therapy, Um, or just going straight down the ambulatory right. I'm bringing them back within two weeks for a repeat X ray with over there is discharge information. Second Kiss is a 45 year old male asthmatic who's hard ongoing cough or wheeze. I woke up overnight with worsening breathlessness. When you see them to the concentrated, they're sweaty, and they have ah, left side of ways bought new breath sounds and right hand side. So traditionally, this was looked upon as the X ray That should be never taken on this attention Pneumothorax. So there is a mediastinal deviation. The key of the heart are old. Push towards the last time having the rocks because the right side is under tension. So this is a case that needs immediate needle decompression on the chest pain and started. Yeah. Next. Yes. Is 32 year old early with a sudden onset right product PM Breathlessness on slightly decreased right side of the air entry again. I don't know how well it comes across on other people screens, but you can see a long edge Common dine. There's about a one centimeter pneumothorax and left of the hilum. And so when this one you could proceed t have the needle aspiration on, then reaction afterwards to see if you've been successful. So are there any questions with thought having Mr No, Hardly even anywhere. So Yeah. Okay. Yeah. Oh, thank you very much for kids. And fisher. I just fax. Um we detention the motorists. We're exactly anatomical. Do we do the compression now? If because it's like I have come across really an acidy best. This should be in the just a, uh um, triangle of safety that are done. The sickling taco star me clavicular. So I don't know, but I've come across that. Yeah, there's two schools of thought, so traditionally, it has being second. Intercostal spaces make curricular nine. Um because in most patients, my voice is going and most patients with a needle that you will get access, the perils bs and the risk of going to the triangle of safety is if they're basically a lot of adipose tissue there a needle might not penetrate the perles for years. If you want to, you can try a needle in the triangle, see if they and that means that all the winds trauma could be in one site. And what does it say? It's It's open toe individual interpretation. Okay, thank you very much.