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  • • Air in pleural space

    • Breach in parietal or visceral pleura

    • Described as percentage of chest cavity involved

    • Open pneumothorax is associated with open sucking chest wound

    • Tension pneumothorax causes shift in mediastinum toward contralateral lung

    • 5-10% small pleural effusion present, may be hemorrhagic

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Epidemiology

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  • • Etiologies of spontaneous pneumothorax include:

    • -Secondary to some pathologic process

      -Rupture of bleb is most common

      -Male:female ratio 6:1

      -Age 16 to 24 years, tall, thin, smoking are risk factors

      -Apical bullae (patients with chronic obstructive pulmonary disease [COPD])

      -Pneumocystic pneumonia

      -Metastatic cancer

      -Rupture of esophagus

      -Lung abscess

      -Cystic fibrosis

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Symptoms and Signs

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  • • Pleuritic chest pain

    • Dyspnea, hypoxia, hypocapnia

    • Diaphoresis, cyanosis, weakness, hypotension, cardiovascular collapse

    • Tachypnea, tachycardia, deviation of trachea away (tension)

    • Decreased breath sounds, hyperresonance, diminished local fremitus

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Laboratory Findings

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  • • ECG: May show nonspecific axis deviation, ST changes, T wave inversion

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Imaging Findings

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  • Chest x-ray: Diagnostic

    CT scan: May help differentiate pneumothorax from apical pleural bleb

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  • • 1 cm pneumothorax correlates with 25% loss of lung volume

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  • • Chest x-ray

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When to Refer

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  • • Patients with cystic fibrosis

    • Patients with AIDS and pneumocystis pneumonia

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  • Small (< 25%), minimal symptoms: Can be monitored conservatively

    Larger asymptomatic, symptomatic, increasing pneumothorax, or associated with effusion:

    • -Insert chest tube

      -Underwater suction drainage or Heimlich (can treat as outpatient)

    • Select patients can get aspiration without chest tube, but 20-50% have recurrence

    • Patients with AIDS and pneumocystis pneumonia has high failure rate and mortality

    • Pleurodesis with doxycycline or talc

    • Axillary thoracotomy with apical bullectomy, parietal pleurectomy, and pleurodesis (preferred technique)

    • Complete parietal pleurectomy

    • Transplantation: Patients with cystic fibrosis or severe COPD; pleurodesis may be contraindicated in these patients

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Indications

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  • • Pleurodesis:

    • -Air leaks > 7 days

      -Lung does not fully expand

      -High-risk occupation (scuba divers, pilots)

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Contraindications

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  • • Pleurodesis:

    • -Cystic fibrosis, severe COPD (relative)

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Treatment Monitoring

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  • • Repeat chest film mandatory within 24 hours of chest tube removal due to recurrence

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Complications

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  • • Recurrence

    • -Spontaneous, 50%

      -After 2 episodes, 75%

      -After 3 episodes, > 80%

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References

Brasel KJ et al: Treatment of occult pneumothoraces from blunt trauma. J Trauma 1999;46:987.  [PubMed: 10372613]
Cothren C et al: Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries. J Trauma 2002;53:483.  [PubMed: 12352485]
Dulchavsky SA et al: Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma 2001;50:201.  [PubMed: 11242282]
Karmy-Jones R et al: Urgent and emergent thoracotomy for penetrating chest trauma. J Trauma 2004;56:664. ...

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