Chapter 32

### Pneumothorax

Key Points

1. A pneumothorax results from a tear in the visceral or parietal pleura with the introduction and/or accumulation of air in the pleural space.

2. A pneumothorax may be spontaneous or, more frequently, acquired.

3. A patient with a pneumothorax may present with respiratory complaints and chest pain, but with minimal lung collapse, the breath sounds may be normal.

4. An upright anterior-to-posterior chest radiograph, upon expiration when feasible, is the standard diagnostic test used to identify a pneumothorax.

5. Treatment may include observation, needle aspiration, placement of an intercostal catheter or tube, or surgical intervention. This may include invasive thoracoscopy or thoracotomy with pleurodesis or pleurectomy, and possibly resection of underlying bullae, cysts, or abnormalities thought to be responsible for the pneumothorax.

6. Surgical treatment using video-assisted thoracoscopic techniques (VATS) or open thoracotomy is indicated when an air leak continues for more than 3 to 5 days or in a pneumothorax that recurs within 48 hours following adequate treatment.

### Introduction

A pneumothorax results from a tear in the visceral or parietal pleura with the introduction and/or accumulation of air in the pleural space. Although known for centuries to occur from penetrating chest injuries, the danger of air in the chest was not appreciated until the late 18th century. During the 19th century, when a pneumothorax was commonly due to tuberculosis, John B. Murphy popularized collapse therapy for treating tuberculosis. In 1932, Kjaergaard described the rupture of a subpleural bleb as the most common cause of pneumothorax.

### Etiology

A pneumothorax may be spontaneous or acquired. A spontaneous pneumothorax is classified as primary or secondary. The most common cause of a primary spontaneous pneumothorax is rupture of an apical subpleural bleb. While this seldom affects prepubescent children, it is more likely to occur in young, tall, thin males, especially those who smoke. It is hypothesized that a rapid increase in the vertical growth compared to the horizontal growth of the thorax increases the negative pressure in the apex of the lung causing the formation of subpleural blebs.

Secondary spontaneous pneumothorax results from a complication of underlying lung disease. The most common causes of secondary spontaneous pneumothorax in children are asthma and cystic fibrosis. A neonate being treated for hyaline membrane disease, meconium aspiration, or other acute pulmonary condition may develop secondary spontaneous pneumothorax from a combination of the disease and treatment with positive pressure ventilation. In older children, cystic fibrosis and Pneumocystis carinii infection associated with immunosuppression are relatively common causes of secondary pneumothorax. Asthma, pneumonia with lung abscess, Marfan syndrome, esophageal rupture, and metastatic cancer can also be associated with secondary pneumothorax.

An acquired pneumothorax is encountered much more frequently than a spontaneous pneumothorax. Blunt and penetrating chest trauma often lead to a pneumothorax and are discussed in Chapter 80. Iatrogenic injury to the pleura or lung from placement of central lines and pacemakers using ...

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