Pneumothorax – Quick Consult |
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Last Updated / Reviewed: June 2022
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Definition
Key History
Key Physical Exam
Risk Factors for Pneumothorax
Differential Diagnosis
Diagnostic Testing
Clinical Risk and Safety Pearls
Treatment
Complications
Pneumothorax
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Collection of gas in the pleural space resulting in collapse of lung on the affected
side
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Primary Spontaneous Pneumothorax (PSP)
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Pneumothorax that occurs without a precipitating event in a person who has no known
underlying lung disease. (Most will end up having unrecognized lung disease.)
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Secondary or Complicated Spontaneous Pneumothorax
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Occurs as a complication of underlying lung disease
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Tension Pneumothorax
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A life threatening condition compromising cardiopulmonary function that requires
immediate treatment, characterized by tachycardia, hypotension, and cyanosis. See
separate topic: Tension pneumothorax
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- Sudden onset dyspnea
- Sudden onset pleuritic chest pain
- May occur at rest or with exertion (primary and secondary respectively)
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- May be asymptomatic
- Referred pain to shoulder
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- Findings on the affected side:
- Diminished breath sounds
- Hyperresonant percussion
- Decreased excursion
- Subcutaneous emphysema
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- Hypoxemia
- Tachypnea
- Tachycardia
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- Acute endometriosis
- Central line placement
- Ehlers-Danlos
- Family history
- Homocystinuria
- Liver biopsy
- Male to female ratio – 6:1
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- Marfan’s Syndrome
- Rapid altitude changes – diving, flying without pressurization
- Smoker to non-smoker ratio – 20:1
- Thoracentesis
- Trauma
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- Pulmonary disease:
- Adult respiratory distress syndrome
- Asthma
- COPD
- Cystic fibrosis
- Lung abscess
- PCP
- Pulmonary fibrosis
- Sarcoidosis
- TB
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Text / literature information and recommendations include:
- Chest x-ray:
- Radiographic Features — The main radiologic feature of a pneumothorax is a white
visceral pleural line, which is either straight or convex towards the chest wall,
separated from the parietal pleura by an avascular collection of gas. No pulmonary
vessels are visible beyond the visceral pleural edge.
- Upright chest radiographs — In upright patients, the accumulation of gas occurs
primarily in an apicolateral location. As little as 50 mL of pleural gas can be
visible. A lateral width of 1 cm corresponds to about a 10 percent pneumothorax.
The size of a pneumothorax is accounted for by the collapsed lung and, to a greater
degree, by the expanding chest cage. Despite a considerable loss of volume, the
collapsed lung preserves its transradiancy because of hypoxic vasoconstriction that
diminishes its blood flow.
- Inspiratory films are recommended as the initial examination of choice for pneumothorax
detection.
- Lateral Decubitus view – a small pneumothorax can be more easily detected in the
lateral decubitus view. In this position, as little as 5 mL of pleural gas is visible
on the non-dependent side.
- Tension pneumothorax — Tension pneumothorax shows a distinct shift of the mediastinum
to the contralateral side and flattening or inversion of the ipsilateral hemidiaphragm.
Should be treated immediately. Take care to differentiate the pleural line from
artifact.
- CT is useful in difficult cases, for example, patients with emphysema as well as
in critically ill patients who cannot tolerate upright or decubitus films. CT is
more sensitive than CXR.
- Ultrasound is being used as well to aid in diagnosis, especially in trauma cases.
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- 5 mL of air can be seen on a lateral decubitus view.
- 50 mL of air can be seen on an upright CXR.
- 500 mL of air must be present to be seen on a supine CXR.
- Tension pneumothorax shifts the mediastinum to the opposite side.
- Catamenial pneumothorax is a pneumothorax associated with menstruation. Seen in
women with pelvic endometriosis; rarely seen in women ages 30-50 years. Typically
affects the right lung within 72 hours of the onset of menses. Thought to be related
to endometriosis involving the pleura
- Pregnancy: Pneumothorax is a rare complication of labor and delivery and should
be suspected in the pregnant or post partum patient with dyspnea and chest pain
(also consider PE).
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Common text / literature recommendations include:
Supplemental oxygen
Pneumothorax treatment recommendations
Small Spontaneous
Pneumothorax
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Clinically stable with mild symptoms:
- various definitions of “small” exist:
- less than 15% = less than 1 cm wide confined to upper third of chest
- less than 25% of apex down = less than 4 cm apically and less than 1 cm laterally
- less than or equal to 3 cm between lung and chest wall
- treatment is: Observation, reabsorption rate of 1 % per day or usually 3 – 4 days.
May discharge home if asymptomatic. Consider repeat CXR in 6 hours, if no increase
in size may d/c home
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Larger Pneumothorax
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Clinically stable:
- Needle aspiration if less than 50% or tube thoracostomy if greater than 50%
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Larger Pneumothorax
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Clinically unstable:
- Chest tube thoracostomy. Needle decompression may be performed if chest tube insertion
is delayed
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Secondary Pneumothorax
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Typically requires tube thoracostomy although some success has been had with observation
if it is small.
Admit all patients with chest tubes.
It is prudent to admit patients with secondary pneumothorax as they likely have
a diminished pulmonary reserve.
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A patient with a small pneumothorax with mild symptoms who is stable may be discharged
for follow-up in 24 hours for repeat CXR and evaluation after an adequate observation
period.
Tube thoracostomy Indications:
- Air transport
- General anesthesia
- Hemothorax with pneumothorax
- Patient is symptomatic
- Patient is intubated - place a chest tube if positive pressure ventilating a traumatic
pneumothorax in order to prevent a tension pneumothorax
- Pneumothorax is >15-20% and due to trauma
- Pneumothorax is bilateral
- Pneumothorax is enlarging
- Recurrent pneumothorax after a chest tube removal
- Respiratory distress
- Tension pneumothorax
- Traumatic cause of pneumothorax (most)
Percutaneous drainage of pneumothorax (simple aspiration) is successful in 65-70%
of patients with moderate-sized primary spontaneous pneumothorax and in only approximately
35% of patients with secondary spontaneous pneumothorax. In a randomized study of
needle aspiration versus tube thoracostomy, there was a higher immediate recurrence
rate with the needle aspiration, although approximately 66% of patients experienced
resolution of their pneumothorax. The recurrence rates at 3 months were similar
to those for patients treated initially with tube thoracostomy
Bronchoscopy treatment recommendations
Bronchoscopy:
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For large air leaks, removal of foreign body or mucous plugs, and to identify trauma
which may need surgical repair.
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