Pneumothorax – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • Accumulation of air or gas between the parietal and visceral pleurae
  • Spontaneous pneumothorax (SP) may be primary (PSP) or secondary (SSP).
  • PSP occurs in healthy adults with no underlying lung disease (age 20s); rarely in patients >40 years of age.
  • SSP is a complication of underlying lung disease [e.g., chronic obstructive pulmonary disease (COPD), cystic fibrosis, acquired immune-deficiency syndrome (AIDS), or tuberculosis (TB)].
  • Traumatic pneumothorax, both closed and open, may exist in tandem with hemothorax.
  • Tension pneumothorax (TP): Inspired air accumulates into the pleural space with no means of escape. More air increases lung compression and causes hypoxia and hemodynamic compromise.
  • Occult pneumothorax (OP) is not suspected on the basis of clinical exam or plain radiography but is detected with thoracoabdominal CT scanning.
  • System(s) affected: Pulmonary; Cardiovascular
  • Synonym(s): Collapsed lung

Epidemiology

Incidence

  • >20,000 new SP cases occur each year in the US at a cost of >$130 million.
  • Predominant sex: Male > Female.
  • Predominant age: PSP 10–40 years of age; SSP >60 years of age

Prevalence

  • 25–50% recurrence rate of SSP within 1 year:
  • PSP: 7.4-18/100,000 in men, 1.2-6/100,000 in women
  • SSP: 6.3/100,000 in men, 2/100,000 in women

Geriatric Considerations

Higher rates of morbidity and mortality

Pediatric Considerations

Incidence is 1–2% of all neonates, associated with meconium aspiration and respiratory distress syndrome.

Pregnancy Considerations

Rare complication of labor and delivery

Risk Factors

  • Traumatic pneumothorax:
    • Trauma (penetrating injury, broken rib, ruptured bronchus, perforated esophagus)
    • Iatrogenic/postprocedure: Intubation, central line placement, liver biopsy, mechanical ventilation, thoracentesis, cardiopulmonary resuscitation (CPR; seen in 3% of ICU patients)
    • Self-inflicted in intravenous drug abusers (attempting to access internal jugular vein)
  • Spontaneous pneumothorax:
    • Cigarette smoking (increases risk 20×)
    • Airway disease: COPD, asthma, cystic fibrosis
    • Infection: Pneumocystis pneumonia, TB, necrotizing pneumonia
    • Malignancy: Lung cancer, sarcoma
    • Connective tissue disorder: Marfan or Ehlers-Danlos syndrome, scleroderma, rheumatoid arthritis, ankylosing spondylitis
    • Interstitial lung disease: Sarcoidosis, idiopathic pulmonary fibrosis, histiocytosis X, lymphangioleiomyomatosis
    • Bronchial obstruction or foreign body
    • Scuba diving
    • Loss of airplane cabin pressure

Genetics

  • Possible predisposition in tall, thin young men, especially those with marfanoid habitus
  • Multiple modes of inheritance proposed/observed: Autosomal dominant, recessive, X-linked recessive pattern
  • Birt-Hobb-Dube syndrome: Autosomal dominant, associated with lung cysts, benign skin tumor, renal cancer; the FLCN mutation has been mapped to chromosome 17p11.2.

General Prevention

  • Smoking cessation
  • Advise use of seatbelts while driving.
  • With subclavian vein cannulation, use a supraclavicular rather than an infraclavicular approach.

Pathophysiology

Loss of negative intrapleural pressure, lung collapse

Etiology

  • Perforation of the visceral pleura and entry of gas from the lung
  • Penetration of the chest wall, diaphragm, mediastinum, or esophagus
  • Blunt thoracic trauma
  • Gas generated by microorganisms in an empyema

Commonly Associated Conditions

See Risk Factors.

Diagnosis

History

  • Chest trauma
  • Pleuritic chest pain
  • Cough
  • Dyspnea
  • Moderate to severe: Profound respiratory distress, shock, circulatory collapse
  • Referred pain to shoulder or back
  • Rapid, shallow breathing

Physical Exam

  • Asymmetry of respirations
  • Diminished breath sounds on affected side
  • Decreased fremitus
  • Absent egophony and bronchophony on affected side
  • Hyperresonance to percussion
  • Crepitus over chest wall and neck
  • Tachycardia
  • Respiratory distress
  • Cyanosis
  • Tension pneumothorax: Weak, rapid pulse; pallor; neck vein distention; anxiety; tracheal deviation away from affected side; hypotension; altered mental status
  • Consider TP with sudden onset of tachycardia and hypotension in patients on ventilator (especially asthmatic/COPD patients).

Diagnostic Tests & Interpretation

Lab

Initial lab tests

  • Arterial blood gases (ABGs; not diagnostic): Typically elevated A–a gradient and acute respiratory alkalosis
  • Electrocardiogram (ECG): Not diagnostic but may show axis deviation, nonspecific ST-segment changes, T-wave inversion

Imaging

Initial approach

  • Chest X-rays (CXRs):
    • Upright CXR usually is sufficient, but lateral, expiratory, or decubitus position is recommended in equivocal cases.
    • White visceral pleural line separated by a space with no lung/vascular markings adjacent to chest wall
    • Deep sulcus sign: Low lateral costophrenic angle on affected side
    • TP: Mediastinal shift to contralateral side
  • CT scan: Most useful for
    • Trauma patients
    • Small pneumothoraces (if diagnosis is necessary)
    • Distinguishing emphysematous bullae from pneumothorax
  • Ultrasound: Useful adjunct in major trauma patients
    • Absence of lung sliding is virtually pathognomic, with a sensitivity of 92–100%. Accurate in identifying size and extension of occult pneumothorax (OP), but this accuracy is lost in 24 h (1)[B]

Differential Diagnosis

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  • Acute coronary syndrome
  • Pericarditis
  • Pulmonary embolism
  • Pleural effusion
  • Pneumonia
  • Dissection
  • Flail chest
  • Hemothorax
  • Asthma/COPD
  • Airway obstruction/foreign body
  • Esophageal perforation
  • Diaphragmatic hernia

Treatment

Medication

First Line

100% O2 accelerates rate of pleural air absorption.

Second Line

See “Pleurodesis” under Surgery/Other Procedures

Additional Treatment

General Measures

  • Monitor vital signs.
  • Treat any underlying condition.
  • Open pneumothorax: Place dressing over wound. Secure only on 3 sides to avoid tension pneumothorax.

Surgery/Other Procedures

  • For 1st time PSP:
    • If small (<2–3 cm, <20%) and few symptoms: Patient may be observed in the emergency department for 3–6 h and discharged if repeat X-ray shows no progression (2)[C].
    • If larger and/or patient is symptomatic:
      • Randomized, controlled trial (RTC) has shown no difference between aspiration and chest tube in outcomes and fewer hospitalizations with aspiration (3)[A], but this should be accepted with caution owing to small sample size in study (4).
      • Aspiration technique: (1) Position patient semisupine at 45°, (2) prep and anesthetize skin, (3) insert a 16-gauge over-the-needle catheter into 2nd anterior intercostal space and aspirate air, (4) extract needle and connect 3-way stopcock and 60-mL syringe, and (5) aspirate until no more air can be removed. There is disagreement as to whether a failed aspiration should be reattempted.
      • Radiologists can place small-bore catheter or small-caliber chest tube over a guide wire and connect to a Heimlich valve or water seal. However, no RCTs compare their effectiveness.
    • If pneumothorax is large, the patient is unstable, or prior treatment has failed:
      • Insert thoracostomy tube (16–22 F) into 4th, 5th, or 6th intercostal space at the midaxillary line and connect to water seal device. Clamp after 12 h of no air leak.
    • If tension pneumothorax:
      • Needle decompression; Insert 19F or larger needle (14- to 16-gauge, 5-cm needle) into the 2nd intercostal space at the midclavicular line over the superior aspect of rib to avoid vessels, and attach a 3-way stopcock. (Failure rate is 10–35%; longer needles are needed for patients with increased chest wall thickness.) Use large syringe to withdraw air. Follow with a chest tube.
  • For recurrent PSP:
    • There is good consensus and clinical evidence that PSP recurrence prevention should be proposed only after a first recurrence (5)[B].
    • Pleurodesis: Superior to simple drainage in reducing recurrence (6)[C]
      • Intrapleural talc: 5 g in 250 mL of isotonic saline; more effective than tetracycline derivatives, but safety concerns still exist.
      • Intrapleural doxycycline: 5 mg/kg or 500 mg in total of 50 mL
      • Pleural abrasion or partial pleurectomy is also used.
      • Sclerosing agents are contraindicated if patient is a possible candidate for future lung transplant because they increase the risk of bleeding during surgery.
      • Side effects: Fever, pain, and acute lung injury
      • Premedicate patients with a benzodiazepine and/or a narcotic for pain.
      • Consider moderate or deep sedation with ketamine, propofol, or etomidate.
      • Decreased effectiveness if concurrent glucocorticoid use or if lung is not fully reexpanded prior to pleurodesis
    • Video-assisted thoracoscopy (VAT) with pleurodesis is recommended for
      • Recurrent PSP, initial SSP
      • Persistent air leak after 3 days
      • Persistent bronchopleural fistula
      • Patient preference or high-risk occupation (e.g., pilot, diver)
      • Open thoracotomy if failed or unavailable VAT
  • For SSP: Patients should be hospitalized; most authors and guidelines recommend immediate chest tube insertion along with recurrence prevention (5)[C].
  • For catamenial pneumothorax: Recurrence prevention after 1st episode and possible hormonal suppression (5)[C]
  • For traumatic/OP:
    • Usually both overt and occult pneumothorax patients get chest tubes.
    • It appears that small to moderate OP can be treated conservatively.
    • Chest tube insertion for OP needing mechanical ventilation is unclear. Retrospective studies indicate that tube thoracostomy may not be required, but two RCTs arrived at opposite conclusions (1)[B].

In-Patient Considerations

Initial Stabilization

  • Stabilize, oxygenation
  • TP is a medical emergency. Do not wait for CXR; decompress as soon as possible.

Admission Criteria

Admit all patients with either a large PSP that does not resolve completely with simple aspiration, recurrent pneumothorax, SSP, or traumatic pneumothorax

Ongoing Care

Follow-Up Recommendations

  • No air travel until radiographs are normal.
  • Athletes with pneumothorax may return to sports activity after 2–3 weeks of rest as symptoms permit; athletes who require inpatient care should have a follow-up CXR before resuming sports activity.

Patient Monitoring

  • Bed rest while chest tube is in place
  • Serial radiographs to document improvement
  • After simple aspiration/tube thoracostomy: Clamp for 24 h, and then remove if no recurrence is seen on radiograph. If lung is not fully reexpanded after 7 days, consider persistent bronchopleural fistula.
  • Outpatient management should include follow-up CXR to document resolution of pneumothorax, typically in several days.

Patient Education

Smoking cessation

Prognosis

  • Air is reabsorbed in days to weeks.
  • Risk of recurrence: For PSP, mean of 30% with range of 16–52%; for SSP, 39–47%.
  • Prognosis is worse depending on comorbidities.

Complications

  • Reexpansion pulmonary edema
  • Bronchopleural fistulas requiring repair

References

1. Ball CG, Kirkpatrick AW, Feliciano DV et al. The occult pneumothorax: what have we learned? Can J Surg. 2009;52:E173–9.

2. Zehtabchi S, Rios CL et al. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Ann Emerg Med. 2008;51:91–100, 100.e1.

3. Wakai A, O’Sullivan RG, McCabe G et al. Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults. Cochrane Database Syst Rev. 2007;CD004479.

4. Gaudio M, Hafner JW et al. Evidence-based emergency medicine/systematic review abstract: Simple aspiration compared to chest tube insertion in the management of primary spontaneous pneumothorax. Ann Emerg Med. 2009;54:458–60.

5. Noppen M, De Keukeleire T et al. Pneumothorax. Respiration. 2008;76:121–7.

6. Gyorik S, et al. Long-term follow up of thoracoscopic talc pleurodesis for primary spontaneous pneumothorax. Eur Resp J. 2007;29(4):757–760.

Codes

ICD9

  • 512.0 Spontaneous tension pneumothorax
  • 512.1 Iatrogenic pneumothorax
  • 512.8 Other spontaneous pneumothorax
  • 860.0 Traumatic pneumothorax without mention of open wound into thorax
  • 860.1 Traumatic pneumothorax with open wound into thorax

Snomed

  • 36118008 Pneumothorax (disorder)
  • 196102003 Spontaneous tension pneumothorax (disorder)
  • 80423007 Spontaneous pneumothorax (disorder)
  • 90070003 Traumatic pneumothorax (disorder)
  • 22897006 traumatic pneumothorax with open wound into thorax (disorder)

Clinical Pearls

  • Primary pneumothorax is unusual in patients over the age of 40. Consider other etiologies in this population.
  • Emergency needle decompression is accomplished in the 2nd intercostal space in the midclavicular line, tracking over the superior margin of the rib if possible.

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