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

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.

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 with 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 [FEV₁] < 1 L), HIV-related Pneumocystis jiroveci infection, cystic fibrosis, or any underlying pulmonary parenchymal disease (see Table 4: Mediastinal and Pleural Disorders: 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 from migration of peritoneal endometrial tissue through diaphragmatic defects or embolization through pelvic veins.

Table 4
Causes of Secondary Spontaneous Pneumothorax Type Disorder More common Pulmonary Asthma   COPD   Cystic fibrosis   Necrotizing pneumonia   Pneumocystis jiroveci 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   Scleroderma Other Sarcoma   Thoracic endometriosis   Tuberous sclerosis

Traumatic pneumothorax is a common complication of penetrating or blunt chest injuries.

Tension pneumothorax is a pneumothorax causing progressive rise in intrapleural pressure to levels that become positive throughout the respiratory cycle and collapse the lung, shift the mediastinum, and impair venous return to the heart. Air continues to get into the pleural space but cannot exit. Without proper 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). It is rarely 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 with inspiration.

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

Symptoms and Signs

Small pneumothoraces are occasionally asymptomatic. Symptoms of pneumothoraces 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 side with the pneumothorax. If the pneumothorax is large, the side with the pneumothorax may be enlarged with the trachea visibly shifted to the opposite side. With tension pneumothorax, hypotension can occur.

Diagnosis

• Upright inspiratory chest x-ray

In stable patients, the diagnosis is suspected in 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.

Pneumothorax

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 5³/10³ = 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 will not collapse symmetrically, the pneumothorax may appear atypical or loculated, and the calculation will not be accurate.

Small pneumothoraces (eg, < 10%) are sometimes overlooked on chest x-ray. Conditions that mimic pneumothorax radiographically include emphysematous bullae, skin folds, folded bed sheets, and overlap of stomach or bowel markings on lung fields.

Tension pneumothorax is suspected in patients with sudden, unexplained hypotension and dyspnea or some risk factor, particularly positive pressure ventilation. If such a patient also has signs of pneumothorax, such as decreased breath sounds and hyperresonance to percussion, tension pneumothorax should be assumed.

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 O₂ until chest x-ray results are available, because O₂ accelerates pleural reabsorption of air. Treatment then depends on the type, size, and effects of 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 obtained 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 mid-clavicular 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 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 Diagnostic and Therapeutic Pulmonary Procedures: Tube Thoracostomy). Symptomatic patients with iatrogenic pneumothoraces are best managed initially with aspiration.

Tension pneumothorax is a medical emergency, and 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 catheter through the chest wall in the 2nd intercostal space at the mid-clavicular 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 three main problems encountered when treating pneumothorax are air leaks, failure of the lung to expand, and 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 a persistent air leak, an endobronchial obstruction, a trapped lung, or a malpositioned chest tube. 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 having been collapsed for > 2 days. Treatment is supportive, with O₂, diuretics, and cardiopulmonary support as needed.

Prevention

Recurrence approaches 50% in the 3 yr after initial spontaneous pneumothorax. The best preventive procedure is a video-assisted thoracic surgery (VATS) procedure in which blebs are stapled and a pleurodesis is created with pleural abrasion, parietal pleurectomy, or talc insufflation; in some medical centers thoracotomy is still used. These procedures are recommended when catheter drainage fails with spontaneous pneumothorax, when there is a recurrent pneumothorax, or in patients with secondary spontaneous pneumothorax. Recurrence after these procedures is < 5%. Patients who cannot undergo thoracoscopy may undergo chemical pleurodesis through a chest tube (see Mediastinal and Pleural Disorders: Treatment), a procedure that, though much less invasive, reduces the recurrence rate to only about 25%.

Last full review/revision February 2008 by Richard W. Light, MD

Content last modified February 2008