Background

Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie, the potential space between the visceral and parietal pleura of the lung). The clinical results are dependent on the degree of collapse of the lung on the affected side. Pneumothorax can impair oxygenation and/or ventilation. If the pneumothorax is significant, it can cause a shift of the mediastinum and compromise hemodynamic stability. Air can enter the intrapleural space through a communication from the chest wall (ie, trauma) or through the lung parenchyma across the visceral pleura. Among the topics this article will discuss are several areas of new information in the medical literature: (1) studies comparing aspiration and tube drainage for treatment of primary spontaneous pneumothorax, (2) long-term follow-up of surgical treatment of pneumothorax, (3) assessment of the impact of pleurodesis on transplantation outcomes in patients with lymphangiomyomatosis, (4) demonstrated utility of ultrasonography in the bedside diagnosis of iatrogenic pneumothorax, and (5) inability of ultrasonography to distinguish between intrapulmonary bullae and pneumothorax. See also Restoring an Air-Free Pleural Space in Pneumothorax.

Primary and secondary spontaneous pneumothorax

Spontaneous pneumothorax is a commonly encountered problem with approaches to treatment that vary from observation to aggressive intervention. Primary spontaneous pneumothorax (PSP) occurs in people without underlying lung disease and in the absence of an inciting event (see the images below).[1] In other words, air enters into the intrapleural space without preceding trauma and without an underlying history of clinical lung disease. However, many patients whose condition is labeled as primary spontaneous pneumothorax have subclinical lung disease, such as pleural blebs, that can be detected by CT scanning. Patients are typically aged 18-40 years, tall, thin, and, often, are smokers.

Radiograph of a patient with a small spontaneous primary

pneumothorax Close radiographic view of patient with a small spontaneous primary pneumothorax (same patient as from the previous image).

Expiratory radiograph of a patient with a small spontaneous primary pneumothorax (same patient as in the previous images). Secondary spontaneous pneumothorax (SSP) occurs in people with a wide variety of parenchymal lung diseases.[1] These individuals have underlying pulmonary pathology that alters normal lung structure (see the image below). Air enters the pleural space via distended, damaged, or compromised alveoli. The presentation of these patients may include more serious clinical symptoms and sequelae due to comorbid conditions.

Computed tomography scan demonstrating secondary spontaneous pneumothorax (SSP) from radiation/chemotherapy for lymphoma.

Iatrogenic and traumatic pneumothorax

Iatrogenic pneumothorax is a traumatic pneumothorax that results from injury to the pleura, with air introduced into the pleural space secondary to diagnostic or therapeutic medical intervention (see the following image). Half a century ago, iatrogenic pneumothorax was predominantly the result of deliberate injection of air into the pleural space for the treatment of tuberculosis (TB). The terminology evolved to the preference for "induced" or "artificial" pneumothorax to indicate pulmonary TB treatment, before arriving at the current classification. Pulmonary TB remains a significant cause of secondary pneumothorax.

Radiograph of an older man who was admitted to the intensive care unit (ICU) postoperatively. Note the right-sided pneumothorax induced by the incorrectly positioned small-bowel feeding tube in the right-sided bronchial tree. Marked depression of the right hemidiaphragm is noted, and mediastinal shift is to the left side, suggestive of tension pneumothorax. The endotracheal tube is in a good position. Traumatic pneumothorax results from blunt trauma or penetrating trauma that disrupts the parietal or visceral pleura (see the images below). Management steps for traumatic pneumothoraces are similar to those for other, nontraumatic causes. If hemodynamic or respiratory status is compromised or an open (communicating to the atmosphere) and/or hemothorax are also present, tube thoracostomy is performed to evacuate air and allow reexpansion of the lung. There is a subset of traumatic pneumothoraces classified as occult; that is, they cannot be seen on chest radiographs but can be seen on CT scans. In general, these can be observed and treated if they become symptomatic.

Illustration depicting multiple fractures of the left upper chest wall. The first rib is often fractured posteriorly (black arrows). If multiple rib fractures occur along the midlateral (red arrows) or anterior chest wall (blue arrows), a flail chest (dotted black lines) may

result, which may result in pneumothorax. with a complete right-sided pneumothorax due to a stab wound.

Radiograph of a patient

Tension pneumothorax
A tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function. Prompt recognition of this condition is life saving, both outside the hospital and in a modern ICU. Because tension pneumothorax occurs infrequently and has a potentially devastating outcome, a high index of suspicion and knowledge of basic emergency thoracic decompression procedures are important for all healthcare personnel. Immediate decompression of the thorax is mandatory when tension pneumothorax is suspected. This should not be delayed for radiographic confirmation. Note the image below.

This chest radiograph has 2 abnormalities: (1) tension pneumothorax and (2) potentially life-saving intervention delayed while waiting for x-ray results. Tension pneumothorax is a clinical diagnosis requiring emergent needle decompression, and therapy should never be delayed for x-ray confirmation.

Pneumomediastinum
Pneumomediastinum is the presence of gas in the mediastinal tissues occurring spontaneously or following procedures or trauma (see the following images). A pneumothorax may occur secondary to pneumomediastinum.

Pneumomediastinum from barotrauma may result in tension

pneumothorax and obstructive shock. This chest radiograph shows pneumomediastinum (radiolucency noted around the left heart border) in this patient who had a respiratory and circulatory arrest in the emergency department after experiencing multiple episodes of vomiting and a rigid abdomen. The patient was taken immediately to the operating room, where a large rupture of the esophagus was repaired.