Pneumothorax

- Results from air in the pleural space that collapses lung tissue
- Leads to a V/Q defect

- Etiologies
- Primary, Spontaneous
è caused by rupture of the subpleural apical blebs

Secondary
è caused by COPD, TB, Trauma, pneumocystics pneumonia, S. aureus
è iatragenic causes
a. thoracentesis
b. subclavian lines
c. mech ventilation
d. bronchoscopy
Penetrating trauma
Non-penetrating trauma (blunt trauma is most common cause)

S/Sx
- sudden-onset, unilateral, pleuritic chest pain
- dyspnea
- acute respiratory distress

PE
- decreased or absent breath sounds
- hyperresonance on percussion
- tracheal deviation (usually in tension pneumothoraces)
- decreased or absent tacticle fremitus

Evaluation
CXR
- diagnostic gold standard
- best observed in upright, end-expiration films
- will show collapsed lung
- may show broken ribs or other signs of associated trauma

TX
Non-operative
- small pneumothoraces may reabsorb spontaneously

Operative
- large and/or tension pneumothoraces may require
a. immediate needle decompression
b. chest tube placement
- following decompression

Pleurodesis
- injection of irritant into pleural space
- helps scar the two pleural layers together
- preventing recurrence and pleural effusion
Tension Pneumothorax

results from positive pressure build-up secondary to a flap valve mechanism (or one-way valve) resulting in total
lung collapse
- tracheal shifting to opposite end
- expansion of chest wall
Increased intrathoraci pressure restricts cardiac output
- may resut in shock and death

Etiologies:
1. penetrating and blunt chest trauma
2. infection
3. positive-pressure mech vent.
4. Iatrogenic
- placement of Central venous line
- epidural thoracic catheter placement

S/Sx:
Acute-onset, unilateral, pleuritic chest pain
Dyspnea/acute respiratory distress
Syncope

PE
Tachypnea, tachycardia
Unilateral decreased or absent breath sounds
Hypreresonance
Decreased or absent tactile fremitus
Falling o2 sat.
Deviated trachae
JVD
Hypotension
Subcutaneous emphysema

Evaluation:
UTZ
- fast with no radiation exposure
- requires bedside UTZ readily available
- guidance for tube placement
CXR
- do not obtain CXR if tension pneumothorax is suspected – immediately decompress the pleural space
- best observed in end-expiratory films
è shows unilateral absence lung parenchyma

TX:
Non-operative
- suppplemental o2 therapy

Operative
Immediate needle decompression (2nd ICS MCLwith 14 or 16-gauge needle)
Followed by chest tube placement
PNEUMOTHORAX

• A pneumothorax is a collection of air within the pleural space in between the lung (visceral pleura) and
the chest wall (parietal pleura) that can lead to partial or complete pulmonary collapse.
• Spontaneous pneumothorax: spontaneously occurring pneumothorax
• Primary spontaneous pneumothorax: occurs in patients without clinically apparent
underlying lung disease
• Secondary spontaneous pneumothorax: pneumothorax occurs as a complication of
underlying lung disease
• Tension pneumothorax: life-threatening variant of pneumothorax characterized by progressively
increasing pressures within the chest and cardiorespiratory compromise

Etiology:

• Spontaneous pneumothorax
• Primary (idiopathic or simple pneumothorax)
• Ruptured subpleural apical blebs
• Risk factors
• Family history
• Male gender
• Asthenic body habitus (slim, tall stature) (e.g., in Marfan syndrome)
• Smoking: 90% of cases; up to 20-fold increase in risk (risk increases with cumulative number of cigarettes
smoked)
• Homocystinuria

• Secondary (pneumothorax as a complication of underlying lung disease)

• Catamenial pneumothorax (extremely rare; thoracic endometriosis)
• Pulmonary tuberculosis
• Cystic fibrosis → bronchiectasis with obstructive emphysema and bleb or cyst rupture
• Pneumocystis pneumonia → alveolitis, rupture of a cavity
• COPD (smoking) → rupture of bullae in emphysema
• Traumatic pneumothorax: blunt (e.g., motor vehicle accident with impact of thorax onto the steering
wheel or rib fracture) or penetrating (e.g., gunshot) injury
• Iatrogenic pneumothorax: Mechanical ventilation (Mechanical ventilation with high PEEP may result
in barotrauma), thoracocentesis, central venous catheter placement, or bronchoscopy
Pathophysiology

• Increased intrapleural pressure → alveolar collapse → decreased V/Q ratio and increased right-to-
left shunting

• Spontaneous pneumothorax: rupture of blebs and bullae → air moves into pleural space with increasing
positive pressure → ipsilateral lungis compressed and collapses
• Traumatic pneumothorax
• Closed pneumothorax: air enters through a hole in the lung (e.g., following blunt trauma)
• Open pneumothorax: air enters through a lesion in the chest wall (e.g., following penetrating
trauma)
• Air enters the pleural space on inspiration and leaks to the exterior on expiration
• Air shifts between the lungs
• Tension pneumothorax: disrupted visceral pleura, parietal pleura, or tracheobronchial tree → air enters
the pleural space on inspiration but cannot exit → progressive accumulation of air in the pleural space and
increasing positive pressure within the chest → collapse of ipsilateral lung and compression
of contralateral lung, trachea, heart, and superior vena cava → impaired respiratory function,
reduced venous return to the heart and reduced cardiac output → hypoxia and hemodynamic instability

Clinical Features:

• Sudden, severe, and/or stabbing, ipsilateral pleuritic chest pain and dyspnea
• Reduced, or absent breath sounds, hyperresonant percussion, decreased fremitus on the ipsilateral side
• Subcutaneous emphysema
• Additionally in tension pneumothorax:
• Severe acute respiratory distress: cyanosis, restlessness, diaphoresis
• Reduced chest expansion on the ipsilateral side
• Distended neck veins and hemodynamic instability (tachycardia, hypotension, pulsus
paradoxus)
• Secondary injuries (e.g., open or closed wounds)

• P-THORAX: Pleuritic pain, Tracheal deviation, Hyperresonance, Onset sudden, Reduced breath
sounds (and dyspnea), Absent fremitus, X-rays show collapse
 Diagnostics

• Suspected pneumothorax is confirmed by chest x-ray.

• Immediate x-ray or an extended focused assessment with sonography for trauma (eFAST) in adults with
severe respiratory compromise and children
• CT may provide detailed information about the underlying cause (e.g., bullae in spontaneous
pneumothorax).
• Tension pneumothorax is primarily a clinical diagnosis and prolonged diagnostic studies should be
avoided to initiate immediate treatment.

Diagnostics II

• Arterial blood gas analysis (ABG) to detect respiratory acidosis

• Chest x-ray (confirmatory test)
• Ideally in two projections (PA and lateral), in supine and upright position
•

• Ipsilateral pleural line with reduced/absent lung markings

• Sudden change in radiolucency
• Areas with abnormal accumulations of air appear “darker” (radiolucent) while a partially
collapsed lung parenchymaappears “brighter” (radiopaque).

• Deep sulcus sign: dark and deep costophrenic angle on the affected side

Especially on CXR in the supine position. A depressed costophrenic angle and sharply defined anterior
diaphragmatic surface because of gaseous collections make this sign visible.

• If pulmonary disease is present: airway or parenchymal lesions

• Additional features in tension pneumothorax:
• Ipsilateral diaphragmatic flattening/inversion and widened intercostal spaces
• Tracheal deviation towards the contralateral side

CT
In stable adults without severe respiratory compromise and responsive to resuscitation. Other indications:

• Presurgical workup
• Suspected underlying lung disease, to determine the likelihood of recurrent disease
• Uncertain diagnosis despite chest x-ray
 ECG
for all patients with anterior chest trauma

• Reduced QRS amplitude in leads V2–V6 in left-sided pneumothorax

• Increased QRS amplitude in leads V5–V6 in right-sided pneumothorax
• ST elevation or depression

Management

• Simple pneumothorax
• If small (≤ 2 to 3 cm between the lung and chest wall on a chest x-ray) and asymptomatic
• Usually resolve spontaneously within a few days (∼ 10 days)
• Supplemental oxygen (4-6 L/min) via nasal cannula or mask with reservoir
• Serial follow-up with repeat CXR
• If small and symptomatic (but hemodynamically stable) or large (> 3 cm between the lung and chest wall on
chest x-ray) primary pneumothorax, iatrogenic, traumatic, or secondary pneumothorax
• Immediate supplemental oxygen (4-6 L/min) via nasal cannula or mask with reservoir
• Upright positioning
• Symptomatic treatment
• Tube thoracostomy

• Open pneumothorax
• Simple partially occlusive dressings taped at 3 out of 4 sides of the lesion
• Followed by thoracostomy
• Observe for development of tension pneumothorax

• Tension pneumothorax
• Emergency chest decompression via chest tube placement if immediately available
• Otherwise perform emergency needle thoracostomy, followed by chest tube placement
Procedures

• Chest tube placement

•

• Bülau drain: 4th intercostal space (nipple line) in between anterior and median axillary line (safe
triangle; midaxillary line)

• Needle thoracostomy
• Immediate insertion of a large-bore needle into the 2nd intercostal space along the midclavicular
line (followed by insertion of a chest tube)