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Pneumothorax

by Richard W. Light, MD

Pneumothorax is air in the pleural space causing partial or complete lung collapse. Pneumothorax can occur spontaneously or result from trauma or medical procedures. Diagnosis is based on clinical criteria and chest x-ray. Most pneumothoraces require transcatheter aspiration or tube thoracostomy.

Etiology

Primary spontaneous pneumothorax occurs in patients without underlying pulmonary disease, classically in tall, thin young men in their teens and 20s. It is thought to be due to spontaneous rupture of subpleural apical blebs or bullae that result from smoking or that are inherited. It generally occurs at rest, although some cases occur during activities involving reaching or stretching. Primary spontaneous pneumothorax also occurs during diving and high-altitude flying because of unequally transmitted pressure changes in the lung.

Secondary spontaneous pneumothorax occurs in patients with underlying pulmonary disease. It most often results from rupture of a bleb or bulla in patients with severe COPD (forced expiratory volume in 1 sec [FEV 1 ] < 1 L), HIV-related Pneumocystis jirovecii infection, cystic fibrosis, or any underlying pulmonary parenchymal disease (see Table: Causes of Secondary Spontaneous Pneumothorax). Secondary spontaneous pneumothorax is more serious than primary spontaneous pneumothorax because it occurs in patients whose underlying lung disease decreases their pulmonary reserve.

Catamenial pneumothorax is a rare form of secondary spontaneous pneumothorax that occurs within 48 h of the onset of menstruation in premenopausal women and sometimes in postmenopausal women taking estrogen . The cause is intrathoracic endometriosis, possibly due to migration of peritoneal endometrial tissue through diaphragmatic defects or embolization through pelvic veins.

Causes of Secondary Spontaneous Pneumothorax

Type

Disorder

More common

Pulmonary

Asthma

COPD

Cystic fibrosis

Necrotizing pneumonia

Pneumocystis jirovecii infection

TB

Less common

Pulmonary

Idiopathic pulmonary fibrosis

Langerhans cell histiocytosis

Lung cancer

Lymphangioleiomyomatosis

Sarcoidosis

Connective tissue disorders

Ankylosing spondylitis

Ehlers-Danlos syndrome

Marfan syndrome

Polymyositis and dermatomyositis

RA

Systemic sclerosis

Other

Sarcoma

Thoracic endometriosis

Tuberous sclerosis

Traumatic pneumothorax is a common complication of penetrating or blunt chest injuries (see Pneumothorax (Traumatic)).

Iatrogenic pneumothorax is caused by medical interventions, including transthoracic needle aspiration, thoracentesis, central venous catheter placement, mechanical ventilation, and cardiopulmonary resuscitation.

Pathophysiology

Intrapleural pressure is normally negative (less than atmospheric pressure) because of inward lung and outward chest wall recoil. In pneumothorax, air enters the pleural space from outside the chest or from the lung itself via mediastinal tissue planes or direct pleural perforation. Intrapleural pressure increases, and lung volume decreases.

Tension pneumothorax (see also Pneumothorax (Tension)) is a pneumothorax causing a progressive rise in intrapleural pressure to levels that become positive throughout the respiratory cycle and collapses the lung, shifts the mediastinum, and impairs venous return to the heart. Air continues to get into the pleural space but cannot exit. Without appropriate treatment, the impaired venous return can cause systemic hypotension and respiratory and cardiac arrest (pulseless electrical activity) within minutes. Tension pneumothorax most commonly occurs in patients receiving positive-pressure ventilation (with mechanical ventilation or particularly during resuscitation). Rarely, it is a complication of traumatic pneumothorax, when a chest wound acts as a one-way valve that traps increasing volumes of air in the pleural space during inspiration.

Symptoms and Signs

Small pneumothoraces are occasionally asymptomatic. Symptoms of pneumothorax include dyspnea and pleuritic chest pain. Dyspnea may be sudden or gradual in onset depending on the rate of development and size of the pneumothorax. Pain can simulate pericarditis, pneumonia, pleuritis, pulmonary embolism, musculoskeletal injury (when referred to the shoulder), or an intra-abdominal process (when referred to the abdomen). Pain can also simulate cardiac ischemia, although typically the pain of cardiac ischemia is not pleuritic.

Physical findings classically consist of absent tactile fremitus, hyperresonance to percussion, and decreased breath sounds on the affected side. If the pneumothorax is large, the affected side may be enlarged with the trachea visibly shifted to the opposite side. With tension pneumothorax, hypotension can occur.

Diagnosis

  • Chest x-ray

The diagnosis is suspected in stable patients with dyspnea or pleuritic chest pain and is confirmed with upright inspiratory chest x-ray. Radiolucent air and the absence of lung markings juxtaposed between a shrunken lobe or lung and the parietal pleura are diagnostic of pneumothorax. Tracheal deviation and mediastinal shift occur with large pneumothoraces.

The size of a pneumothorax is defined as the percentage of the hemithorax that is vacant. This percentage is estimated by taking 1 minus the ratio of the cubes of the width of the lung and hemithorax. For example, if the width of the hemithorax is 10 cm and the width of the lung is 5 cm, the ratio is 5 3 /10 3 = 0.125. Thus, the size of the pneumothorax is about 1 minus 0.125, or 87.5%. If adhesions are present between the lung and the chest wall, the lung does not collapse symmetrically, the pneumothorax may appear atypical or loculated, and the calculation is not accurate.

Small pneumothoraces (eg, < 10%) are sometimes overlooked on chest x-ray. In patients with possible pneumothorax, lung markings should be traced to the edge of the pleura on chest x-ray. Conditions that mimic pneumothorax radiographically include emphysematous bullae, skinfolds, folded bed sheets, and overlap of stomach or bowel markings on lung fields.

Pearls & Pitfalls

  • Sudden hypotension in a mechanically ventilated patient should prompt consideration of tension pneumothorax. If the patient also has decreased breath sounds and hyperresonance to percussion, tension pneumothorax should be presumed and treated immediately without awaiting confirmation by chest x-ray.

Treatment

  • Immediate needle decompression for tension pneumothoraces

  • Observation and follow-up x-ray for small, asymptomatic, primary spontaneous pneumothoraces

  • Catheter aspiration for large or symptomatic primary spontaneous pneumothoraces

  • Tube thoracostomy for secondary and traumatic pneumothoraces

Patients should receive supplemental O 2 until chest x-ray results are available because O 2 accelerates pleural reabsorption of air. Treatment then depends on the type, size, and effects of the pneumothorax. Primary spontaneous pneumothorax that is < 20% and that does not cause respiratory or cardiac symptoms can be safely observed without treatment if follow-up chest x-rays done at about 6 and 48 h show no progression. Larger or symptomatic primary spontaneous pneumothoraces should be evacuated by catheter aspiration. Tube thoracostomy is an alternative.

Catheter aspiration is accomplished by insertion of a small-bore (about 7 to 9 French) IV or pigtail catheter into the chest in the 2nd intercostal space at the midclavicular line. The catheter is attached to a 3-way stopcock and syringe. Air is withdrawn from the pleural space through the stopcock into the syringe and expelled into the room. The process is repeated until the lung re-expands or until 4 L of air are removed. If the lung expands, the catheter can be removed or kept in place attached to a one-way Heimlich valve (thus permitting ambulation), and the patient need not be hospitalized. If the lung does not expand, a chest tube should be inserted, and the patient should be hospitalized. Primary spontaneous pneumothoraces can also be managed initially with a chest tube attached to a water seal without or with suction. Patients with primary spontaneous pneumothoraces should also undergo smoking cessation counseling.

Secondary and traumatic pneumothoraces are generally treated with tube thoracostomy (see Tube Thoracostomy). Symptomatic patients with iatrogenic pneumothoraces are best managed initially with aspiration.

Tension pneumothorax is a medical emergency and should be diagnosed clinically; time should not be wasted confirming the diagnosis with a chest x-ray. It should be treated immediately by inserting a 14- or 16-gauge needle with a catheter through the chest wall in the 2nd intercostal space at the midclavicular line. The sound of high-pressure air escaping confirms diagnosis. The catheter can be left open to air or attached to a Heimlich valve. Emergency decompression must be followed immediately by tube thoracostomy, after which the catheter is removed.

Complications

The 3 main problems encountered when treating pneumothorax

  • Air leaks

  • Failure of the lung to expand

  • Re-expansion pulmonary edema

Air leaks are usually due to the primary defect—ie, continued leakage of air from the lung into the pleural space—but can be due to air leaking around the chest tube insertion site if the site is not properly sutured and sealed. Air leaks are more common in secondary than in primary spontaneous pneumothorax. Most resolve spontaneously in < 1 wk.

Failure of the lung to re-expand is usually due to one of the following:

  • Persistent air leak

  • Endobronchial obstruction

  • Trapped lung

  • Malpositioned chest tube

Blood pleurodesis (a blood patch), thoracoscopy, or thoracotomy should be considered if an air leak or an incompletely expanded lung persists beyond 1 wk.

Re-expansion pulmonary edema occurs when the lung is rapidly expanded, as occurs when a chest tube is connected to negative pressure after the lung has been collapsed for > 2 days. Treatment is supportive, with O 2 , diuretics, and cardiopulmonary support as needed.

Prevention

Recurrence approaches 50% in the 3 yr after initial spontaneous pneumothorax. The best preventive procedure is video-assisted thoracic surgery (VATS) in which blebs are stapled and pleurodesis is done with pleural abrasion, parietal pleurectomy, or talc insufflation; in some medical centers, thoracotomy is still used. These procedures are recommended when catheter aspiration fails to resolve spontaneous pneumothorax, when pneumothorax recurs, or when patients have secondary spontaneous pneumothorax. Recurrence after these procedures is < 5%. If thoracoscopy cannot be done or is contraindicated, chemical pleurodesis through a chest tube may be done (see Malignant pleural effusion); this procedure, though much less invasive, reduces the recurrence rate to only about 25%.

Key Points

  • Primary spontaneous pneumothorax occurs in patients without underlying pulmonary disease, classically in tall, thin young men in their teens and 20s.

  • Secondary spontaneous pneumothorax occurs in patients with underlying pulmonary disease; it most often results from rupture of a bleb or bulla in patients with severe COPD.

  • Diagnosis is by upright chest x-ray, except for tension pneumothorax, which is diagnosed clinically as soon as suspected.

  • Primary spontaneous pneumothorax that is < 20% and that does not cause respiratory or cardiac symptoms can be safely observed without treatment if follow-up chest x-rays done at about 6 and 48 h show no progression.

  • Larger or symptomatic primary spontaneous pneumothoraces should be evacuated by catheter aspiration or tube thoracostomy.

  • Secondary and traumatic pneumothoraces are generally treated with tube thoracostomy.

  • Video-assisted thoracic surgery (VATS) and other procedures can help prevent recurrences of spontaneous pneumothorax, which otherwise occur in 50% of patients within 3 yr.

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