Pneumothorax

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

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

Imaging Findings

• • Chest x-ray: Diagnostic

  • CT scan: May help differentiate pneumothorax from apical pleural bleb

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

• • Chest x-ray

When to Refer

• • Patients with cystic fibrosis

  • Patients with AIDS and pneumocystis pneumonia

• • 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

Indications

• • Pleurodesis:

  • -Air leaks > 7 days

    -Lung does not fully expand

    -High-risk occupation (scuba divers, pilots)

Contraindications

• • Pleurodesis:

  • -Cystic fibrosis, severe COPD (relative)

Treatment Monitoring

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

Complications

• • Recurrence

  • -Spontaneous, 50%

    -After 2 episodes, 75%

    -After 3 episodes, > 80%

References