• Clinical science
  • Physician

Pneumothorax

Summary

A pneumothorax develops when air as the result of disease or injury enters the pleural space, resulting in the loss of negative pressure between the two pleural membranes. This loss of negative pressure leads to the partial or complete collapse of the lung. Pneumothorax is classified as spontaneous (e.g., by rupture of a subpleural bleb or diseased lung), traumatic, or iatrogenic. Each type can lead to a tension pneumothorax, which is a life-threatening variant of pneumothorax. Patients with pneumothorax present with sudden-onset dyspnea, ipsilateral chest pain, diminished breath sounds, and hyperresonant percussion on the affected side. A tension pneumothorax additionally presents with distended neck veins, tracheal deviation, and hemodynamic instability. Both should be suspected on clinical evaluation. While a tension pneumothorax requires immediate chest decompression, a chest x-ray may be considered to confirm the diagnosis in a stable patient. Small pneumothoraces may resorb spontaneously, but treatment of larger defects usually requires placement of a chest tube to re-establish the negative pressure within the pleural space.

Epidemiology

References:[1]

Epidemiological data refers to the US, unless otherwise specified.

Definition

References:[1]

Etiology

A tension pneumothorax may occur with any of the above-mentioned etiologies!References:[1]

Pathophysiology

References:[2]

Clinical features

Clinical features vary from asymptomatic to cardiopulmonary compromise

  • Sudden, severe, and/or stabbing, ipsilateral pleuritic chest pain and dyspnea
  • Reduced, or absent breath sounds, hyperresonant percussion, decreased fremitus on the ipsilateral side
  • Subcutaneous emphysema
  • Additionally in tension pneumothorax:
    • Severe acute respiratory distress: cyanosis, restlessness, diaphoresis
    • Reduced chest expansion on the ipsilateral side
    • Distended neck veins and hemodynamic instability; (tachycardia, hypotension, pulsus paradoxus)
    • Secondary injuries (e.g., open or closed wounds)

P-THORAX: Pleuritic pain, Tracheal deviation, Hyperresonance, Onset sudden, Reduced breath sounds (and dyspnea), Absent fremitus, X-rays show collapse.References:[1][3]

Diagnostics

General

  • Suspected pneumothorax is confirmed by chest x-ray.
    • Immediate x-ray or an extended focused assessment with sonography for trauma (eFAST) in adults with severe respiratory compromise and children
  • CT may provide detailed information about the underlying cause (e.g., bullae in spontaneous pneumothorax).
  • Tension pneumothorax is primarily a clinical diagnosis and prolonged diagnostic studies should be avoided to initiate immediate treatment.

Diagnostic tests

Arterial blood gas analysis (ABG)

Chest x-ray (confirmatory test)

Chest CT

  • In stable adults without severe respiratory compromise and responsive to resuscitation. Other indications :
    • Presurgical workup
    • Suspected underlying lung disease, to determine the likelihood of recurrent disease
    • Uncertain diagnosis despite chest x-ray

ECG

  • For all patients with anterior chest trauma
    • Reduced QRS amplitude in leads V2–V6 in left-sided pneumothorax
    • Increased QRS amplitude in leads V5–V6 in right-sided pneumothorax
    • ST elevation or depression

A negative eFAST does not exclude a pneumothorax!

In cases of tension pneumothorax, immediate decompression is a priority and should not be delayed by imaging!

References:[1][4]

Differential diagnoses

For details and further differential diagnoses, see differential diagnoses of acute chest pain.

The differential diagnoses listed here are not exhaustive.

Treatment

Approach

  • Simple pneumothorax
    • If small (≤ 2 to 3 cm between the lung and chest wall on a chest x-ray) and asymptomatic
      • Usually resolve spontaneously within a few days (∼ 10 days)
      • Supplemental oxygen (4-6 L/min) via nasal cannula or mask with reservoir
      • Serial follow-up with repeat CXR
    • If small and symptomatic (but hemodynamically stable) or large (> 3 cm between the lung and chest wall on chest x-ray) primary pneumothorax, iatrogenic, traumatic, or secondary pneumothorax
      • Immediate supplemental oxygen (4-6 L/min) via nasal cannula or mask with reservoir
      • Upright positioning
      • Symptomatic treatment
      • Tube thoracostomy
  • Open pneumothorax
    • Simple partially occlusive dressings taped at 3 out of 4 sides of the lesion
    • Followed by thoracostomy
    • Observe for development of tension pneumothorax
  • Tension pneumothorax
    • Emergency chest decompression via chest tube placement if immediately available
    • Otherwise perform emergency needle thoracostomy, followed by chest tube placement

Procedures

Tension pneumothorax is a clinical diagnosis and medical emergency! Immediate emergency chest decompression is indicated! Do not intubate and ventilate without decompressing first!

Acute management checklist

Acute management checklist for tension pneumothorax [5][6]

Acute management checklist for spontaneous pneumothorax [7][5][8]

All patients

Primary spontaneous pneumothorax

  • Clinically stable (RR < 24/minute, HR 60–120/minute, normotensive, SpO2 > 90% on room air, patient can speak in full sentences without dyspnea) with small pneumothorax (< 3 cm)
    • Monitor closely.
    • Order repeat CXR in 3–6 hours.
  • Clinically stable with large pneumothorax (≥ 3 cm)
  • Clinically unstable with large pneumothorax (≥ 3 cm)
    • Chest tube with water seal with or without suction
    • Order repeat CXR after chest tube insertion.
    • ICU transfer

Secondary spontaneous pneumothorax

  • Clinically stable (RR < 24/minute, HR 60–120/minute, normotensive, SpO2 > 90% on room air, patient can speak in full sentences without dyspnea) with small pneumothorax (< 3 cm)
    • Admission with monitoring for 24 hours should be considered.
    • Consider chest tube to water seal or Heimlich valve until lung re-expands.
    • Order repeat CXR after chest tube insertion.
    • Consult thoracic surgery.
  • Clinically stable with large pneumothorax (≥ 3 cm) or clinically unstable
    • Chest tube insertion to water seal or Heimlich valve until lung re-expands
    • Order repeat CXR after chest tube insertion.
    • ICU transfer
    • Consult thoracic surgery.

Complications

References:[1]

We list the most important complications. The selection is not exhaustive.

  • 1. Daley BJ, Mancini MC. Pneumothorax. In: Pneumothorax. New York, NY: WebMD. http://emedicine.medscape.com/article/424547-overview#a5. Updated July 20, 2016. Accessed December 7, 2016.
  • 2. Choi WI. Pneumothorax. Tuberc Respir Dis (Seoul). 2014; 76(3): pp. 99–104. doi: 10.4046/trd.2014.76.3.99.
  • 3. Shankar PS . Subcutaneous Emphysema From Bronchocavitary Subcutaneous Fistula. Lung India. 2008; 25(2): pp. 73–74. doi: 10.4103/0970-2113.44123.
  • 4. Agabegi SS, Agabegi ED. Step-Up To Medicine. Baltimore, MD, USA: Lippincott Williams & Wilkins; 2013.
  • 5. Leech C, Porter K, Steyn R, et al. The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh. Trauma. 2016; 19(1): pp. 54–62. doi: 10.1177/1460408616664553.
  • 6. Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. Emergency Medicine Journal. 2004; 22(1): pp. 8–16. doi: 10.1136/emj.2003.010421.
  • 7. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001; 119(2): pp. 590–602. doi: 10.1378/chest.119.2.590.
  • 8. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010; 65(Suppl 2): pp. ii18–ii31. doi: 10.1136/thx.2010.136986.
  • Herold G. Internal Medicine. Cologne, Germany: Herold G; 2014.
  • Thomsen L, Natho O, Feigen U, Schulz U, Kivelitz D. Value of Digital Radiography in Expiration in Detection of Pneumothorax. RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren. 2013; 186(03): pp. 267–273. doi: 10.1055/s-0033-1350566.
  • Alrajab S, Youssef AM, Akkus NI, Caldito G. Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Critical Care. 2013; 17(5): p. R208. doi: 10.1186/cc13016.
  • Tschopp J-M, Bintcliffe O, Astoul P, et al. ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax. European Respiratory Journal. 2015; 46(2): pp. 321–335. doi: 10.1183/09031936.00219214.
  • Porcel JM. Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists. Tuberculosis and Respiratory Diseases. 2018; 81(2): p. 106. doi: 10.4046/trd.2017.0107.
last updated 01/16/2020
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