Updated: 12/22/2021

Pneumothorax

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  • Snapshot
    • A 22-year-old man presents to the emergency department with chest pain. He was playing basketball when his symptoms suddenly started. The patient is a tall man, and there is no observable trauma to the chest wall. He is hemodynamically stable and currently endorses pleuritic chest pain. (Pneumothorax)
  • Introduction
    • Clinical definition
      • air entry into the chest cavity that causes collapse of the lung without signs of tension physiology (hypotension, tachycardia, and jugular venous distention (JVD))
      • primary pneumothorax
        • no underlying pulmonary disease
      • secondary pneumothorax
        • underlying pulmonary disease
  • Epidemiology
    • Demographics
      • primary pneumothorax
        • tall and thin men
    • Risk factors
      • secondary pneumothorax
        • smoking
  • ETIOLOGY
    • Pathogenesis
      • mechanism
        • rupture of an emphysematous bleb
    • Associated conditions
      • primary pneumothorax
        • a spontaneous process
      • secondary pneumothorax
        • COPD
        • asthma
        • cystic fibrosis
        • infection (pneumonia, abscess, and tuberculosis)
        • interstitial lung disease
        • connective tissue disease
        • procedures (subclavian lines, thoracentesis, bronchoscopy, and mechanical ventilation)
        • blunt trauma
  • Presentation
    • Symptoms
      • sudden-onset, unilateral, pleuritic chest pain
      • dyspnea
    • Physical exam
      • decreased or absent breath sounds
      • hyperresonance on percussion
      • absence of tracheal deviation/JVD (this would imply a tension pneumothorax)
      • decreased or absent tactile fremitus
  • IMAGING
    • Diagnostic testing
      • chest radiograph
        • best initial test
          • will show collapsed lung (lack of pulmonary markings extending to periphery)
      • computed tomography (CT) of the chest
        • most accurate test
          • often not indicated but can be ordered if clinical suspicion with a normal appearing chest radiograph
          • can further elucidate other injuries (rib fractures)
      • ultrasound
        • will demonstrate an absence of lung sliding
  • Differential
    • Primary spontaneous pneumothorax
    • Secondary spontaneous pneumothorax
    • Tension pneumothorax
      • distinguishing factor
        • tension physiology present (hypotension, tachycardia, JVD, and poor O2 saturation)
        • can be associated with procedures such as central line placement
    • Panic attack
      • distinguishing factor
        • only sinus tachycardia without other organic etiologies of symptoms
  • Treatment
    • Management approach
      • always start with the ABC's of trauma prior to diagnostic testing
    • Small pneumothorax, stable vitals, and asymptomatic patient
      • 100% oxygen and observation
        • the pneumothorax will resorb
    • Large pneumothorax and symptomatic patient
      • aspiration (needle thoracocentesis)
      • chest tube/pigtail catheter
        • indications
          • lower threshold to place chest tube if a secondary pneumothorax
          • can be primary treatment or if needle aspiration fails
    • Recurrent pneumothorax
      • video-assisted thoracoscopic surgery
      • pleurodesis
        • injection of an irritant into pleural space scars pleural layers together
  • Complications
    • Recurrence
    • Bilateral pneumothoraces can cause hemodynamic instability
    • May progress to a tension pneumothorax

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